Safe Dosage and Side Effects of Propranolol for Children with Arrhythmia

Q: Safe Dosage and Side Effects of Propranolol for Children with Arrhythmia

Hello： In cases of pediatric arrhythmia, the dosage of propranolol is calculated based on a weight of 20 kg. <br>The initial treatment dose is generally 10 mg/day, and the maintenance dose can be increased by 20 mg/day every 3-4 days, reaching a maximum dose of 60 to even 80 mg/d

Pediatric cardiac medications

Hello, Pharmacist Liao.
My son is 6 years old and weighs 20 kg.
He was diagnosed with arrhythmia (premature ventricular contractions and supraventricular tachycardia) at the beginning of August this year.
He has been taking propranolol 0.5 mg four times a day for two months.
Since starting the medication, my son's emotional fluctuations have been quite significant, and there hasn't been much improvement in his abnormal heart rhythms.
During the recent follow-up, the doctor increased the dosage to 1 mg three times a day.
I would like to know if it is safe for a child of this age and weight to take up to 30 mg of propranolol per day.
I have checked the medication leaflet, and it does indicate that this medication can cause side effects such as depression and mood disturbances (there are no specific dosing recommendations for children).
I have discussed my son's condition with the doctor, but he did not consider it likely that the medication was the cause.
Currently, my son experiences episodes of tachycardia 4-5 times a day, and I am really hesitant to give him the 1 mg three times a day dosage.
I would like to ask the pharmacist about the safe dosage for a 6-year-old child weighing 20 kg and the possible side effects.
Thank you—this is from a very concerned mother.

BoBo Ma, 30~39 year old female. Ask Date: 2018/11/05

Dr. Liao Lingmei reply Pharmacology

Hello: In cases of pediatric arrhythmia, the dosage of propranolol is calculated based on a weight of 20 kg.
The initial treatment dose is generally 10 mg/day, and the maintenance dose can be increased by 20 mg/day every 3-4 days, reaching a maximum dose of 60 to even 80 mg/day.
According to your physician's instructions, the current dose is 30 mg/day, so there is no need for excessive concern.

Based on the pharmacological effects of propranolol, there may be potential psychological impacts, which are documented in the medication insert and international pharmaceutical databases (Micromedex).
However, this is not mentioned in the medical information database (UpToDate), which may lead the physician to consider the correlation to be low.
Psychological side effects, such as confusion, are more commonly observed in elderly patients, while in younger patients, common issues include depression (which may manifest as loss of appetite, difficulty concentrating, social withdrawal, or nightmares).
These side effects typically resolve upon discontinuation of the medication and are not permanent.

Theoretically, while the incidence of side effects may be documented in literature, for the patient taking the medication, it is often perceived as either 0% or 100%.
After weighing the risks and benefits, physicians will still select medications according to treatment guidelines.
Parental involvement is crucial in treating pediatric conditions, so please assess the child's individual needs and treatment responses, and provide feedback to the physician regarding treatment outcomes for a smoother therapeutic process.
Wishing you health and happiness!

Reply Date: 2018/11/05

More Info

Propranolol is a non-selective beta-blocker commonly used to manage various cardiovascular conditions, including arrhythmias, hypertension, and anxiety-related symptoms. When it comes to pediatric patients, especially children like your son who is 6 years old and weighs 20 kg, it is crucial to carefully consider the dosage and potential side effects.

Safe Dosage for Children
For children, the typical starting dose of propranolol for managing arrhythmias is often around 0.5 to 1 mg/kg per day, divided into two to four doses. In your son's case, at 20 kg, this would translate to a starting dose of approximately 10 to 20 mg per day. The maximum recommended dose can vary, but some guidelines suggest that doses can be increased to a maximum of 60 mg per day, depending on the clinical situation and response to treatment.
Currently, your son is taking 30 mg per day, which is within the acceptable range for his weight. However, the increase to 1 tablet three times a day (TID) should be approached with caution, especially considering the emotional and physical side effects he is experiencing. It is essential to monitor his response closely and communicate any concerns with his healthcare provider.

Potential Side Effects
Propranolol can cause a variety of side effects, some of which may be more pronounced in children. Common side effects include:
- Fatigue or Drowsiness: Children may experience increased tiredness or lethargy.

- Dizziness or Lightheadedness: This can occur, especially when standing up quickly.

- Bradycardia: A slower than normal heart rate, which can be concerning in a child with existing heart issues.

- Gastrointestinal Issues: Nausea, vomiting, or diarrhea may occur.

- Mood Changes: There is a documented risk of mood alterations, including depression and anxiety. This is particularly concerning given your observation of significant emotional fluctuations in your son since starting the medication.

While the prescribing information does not provide specific guidelines for children, the potential for mood changes and emotional disturbances is recognized. It is essential to discuss these symptoms with your child's doctor, as they may consider adjusting the dosage or exploring alternative treatments.

Monitoring and Communication
Given your son's ongoing symptoms of arrhythmia and the emotional side effects he is experiencing, it is vital to maintain open communication with his healthcare provider. If you notice that his heart rate continues to be erratic or if his emotional state worsens, do not hesitate to reach out for further evaluation.
In some cases, a referral to a pediatric cardiologist or a pediatric psychiatrist may be warranted to ensure that both the physical and emotional aspects of his health are being addressed appropriately.

Conclusion
In summary, while propranolol can be an effective treatment for arrhythmias in children, careful consideration of the dosage and monitoring for side effects is crucial. Your son's current dosage of 30 mg per day is within the acceptable range for his weight, but the emotional side effects you have observed should be taken seriously. Always consult with your healthcare provider regarding any concerns, and consider advocating for a comprehensive approach to your son's treatment that addresses both his physical and emotional health.

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